Saturday, November 14, 2009

Chemotherapy errors.... what gives?

To the credit to the team involved they reacted pretty quickly and didn't try and sweep the error under the carpet. But what a horrendous error! It is no comfort to say that errors like this can happen, and can happen elsewhere as well...

The question is how can such a monumental error occur in a situation which should be regarded as nothing less than 100% error free. I am sure the hospital and the MOH are now scrambling with their Boards of Inquiries.

But I can tell how 2 people checking a procure can make an error.

There are simply 2 people looking at different things and not really checking with each other. I have seen it happen so many times in ward procedures, and you wonder what is the intention for the checking process. Clearly a checking process is instituted without understanding what the process is supposed to check. Take for example the checking on NRIC numbers.... Staff#1 reads of the case sheet while Staff#2 'checks' the number on the patient's bracelet. Sounds good. But wait..... if Staff#2 didn't get enough sleep and reads an 8 for a 3, even if you repeat the process 10 times, the same error will be reproduced. It is true that the chance of a nexus between a case sheet with an 8 meeting a bracelet with a 3 is very small, but when it does occur the error will not be detected. It's like trying to proof read your own report.

Likewise, in this case.

If Staff#1 reads the instructions and Staff#2 inputs the programme, and if Staff#2 makes the error of inputting hours instead of days, the error will be neither be detected nor prevented. The process only prevents errors caused by the same staff reading and inputting the error.

People who write such procedures need to rethink a bit more about what they are doing...